Histopathologic Manifestations of Crohn Disease in Duodenal Endoscopy Biopsy: The Value of Different Patterns of Involvement of Brunner Glands

Crohn disease (CD) not uncommonly involves the upper gastrointestinal tract, usually gastric antrum and proximal duodenum. The most consistent histopathologic manifestations of CD in duodenal biopsies are mucosal erosion, focal active inflammation, and granulomas. Since CD is a transmural inflammation and since duodenal biopsy may include submucosal Brunner glands, we aimed to find if CD has any specific histopathologic manifestations in Brunner gland lobules and their ducts compared to other duodenal inflammatory lesions. We carried out a retrospective review study over 6 years retrieving duodenal biopsy specimens in CD patients. We compared duodenal specimens involved by CD with other inflammatory lesions, for example, ulcerative colitis (UC), Helicobacter pylori-associated gastritis, non-Helicobacter gastritis, Celiac sprue, infections, and drugs. We found focal active duodenitis and erosion in CD cases and non-CD cases. Granulomas were found in CD cases. Five cases of CD showed inflammatory and degenerative changes of Brunner glands. Focal patchy active inflammation of only portion of submucosal Brunner gland lobule, mucosal Brunner glands, and their ducts was solely found in CD cases. This focally enhanced inflammation of Brunner glands was not found in other lesions. Whether this phenomenon of focal active “lobulitis” and “ductitis” is a specific sign of duodenal CD compared to UC and other inflammatory lesions warrants verification. We encourage endoscopists to include submucosal Brunner lobules in their duodenal biopsy samples and pathologists to look for these patterns of involvement particularly in patients suspected of CD.

Hiperplasia da glândula de Brunner mimetizando tumor gastrointestinal / Brunner’s gland hyperplasia mimetizing gastrointestinal tumor

Introdução: A hiperplasia da glândula de Brunner é uma lesão proliferativa rara e benigna das glândulas de Brunner, glândulas exócrinas localizadas no duodeno, e juntamente com o hamartoma, representam cerca de 5-10% dos tumores duodenais. A nomenclatura sobre essas lesões ainda não está bem estabelecida na literatura, podendo causar dificuldade diagnóstica. A proliferação anormal das glândulas de Brunner é classificada como hiperplasia, contendo múltiplas pequenas lesões polipóides ou nodulares ao longo do duodeno, menores que 5mm. O hamartoma é definido como massa solitária que contém uma mistura de ácinos, ductos, músculo liso, tecido adiposo e tecido linfóide, maiores que 5mm. Geralmente as lesões das glândulas de Brunner são um achado incidental e os pacientes são comumente assintomáticos, ocorrendo na 5ª a 6ª décadas de vida, sem predileção por sexo. Quando sintomáticos, os pacientes podem apresentar sangramento gastrointestinal, obstrução duodenal, dor abdominal, obstrução ampular ou intussuscepção. Há relatos de possível transformação maligna, sendo assim recomendada a ressecção endoscópica ou cirúrgica nos casos suspeitos, após realizar um amplo diagnóstico diferencial de massas duodenais. Objetivo: Relatar um caso raro de hiperplasia das glândulas de Brunner mimetizando tumor do trato gastrointestinal e a importância do seu diagnóstico correto. Relato do caso: Paciente com diagnóstico prévio de neoplasia do trato gastrointestinal em seguimento oncológico, procurou atendimento com queixa de dor abdominal difusa, sem outros sintomas associados. Ao exame físico referiu leve desconforto abdominal à palpação. Exames laboratoriais sem alterações. Foram solicitados exames de imagem complementares, evidenciando lesão no bulbo duodenal, levantando as principais hipóteses diagnósticas de Brunneroma, Lipoma ou GIST. Paciente foi submetida à biópsia e análise anatomopatológica com diagnóstico morfológico de Hiperplasia de glândulas de Brunner. Por se tratar de uma lesão benigna, foi optado manter acompanhamento clínico, evitando submeter a paciente à intervenções cirúrgicas desnecessárias. As informações foram obtidas por meio de revisão do prontuário, entrevista com o paciente, registro dos métodos diagnósticos, incluindo anatomopatológico e exames de tomografia computadorizada, ressonância magnética e PET/CT, bem como uma breve revisão da literatura. Conclusão: Relatamos um caso de hiperplasia da glândula de Brunner mimetizando neoplasia nos exames de tomografia computadorizada, ressonância magnética e PET/CT, demonstrando um desafio diagnóstico e a importância do conhecimento dos diagnósticos diferenciais na avaliação de massas duodenais.Palavras Chave: Glândulas de Brunner, Hiperplasia, Hamartoma, Neoplasias duodenais, Trato gastrointestinal, Diagnóstico por imagemABSTRACT:Introduction: Brunner’s gland hyperplasia is a rare and benign proliferative lesion of the Brunner glands, exocrine glands located in the duodenum, and together with the hamartoma, represent about 5-10% of duodenal tumors. The nomenclature of these lesions is not yet well established in the literature and may cause diagnostic difficulty. Abnormal proliferation of Brunner’s glands is classified as hyperplasia, containing multiple small polypoid or nodular lesions throughout the duodenum, smaller than 5 mm. Hamartoma is defined as a solitary mass containing a mixture of acini, ducts, smooth muscle, adipose tissue and lymphoid tissue, bigger than 5mm. Brunner’s gland lesions are usually an incidental finding and patients are commonly asymptomatic, occurring in the 5th to 6th decades of life, with no gender preference.When symptomatic, patients may have gastrointestinal bleeding, duodenal obstruction, abdominal pain, ampullary obstruction, or intussusception. Possible malignant transformation has been reported, so endoscopic or surgical resection in suspected cases is recommended after a wide differential diagnosis of duodenal masses. Objectives: Report a rare case of Brunner’s gland hyperplasia mimicking gastrointestinal tract tumor and the importance of its correct diagnosis. Case report: A patient with a previous diagnosis of neoplasia of the gastrointestinal tract in oncological follow-up, sought care with complaints of diffuse abdominal pain, without other associated symptoms. On physical examination, she reported mild abdominal discomfort on palpation. Laboratory tests without changes. Complementary imaging exams were requested, showing lesion in the duodenal bulb, raising the main diagnostic hypotheses of Brunneroma, Lipoma or GIST. Patient underwent biopsy and anatomopathological analysis with morphological diagnosis of Brunner’s gland hyperplasia. As it is a benign lesion, it was decided to maintain clinical follow-up, avoiding unnecessary surgical interventions. Information was obtained by reviewing the medical record, interviewing the patient, recording diagnostic methods, including histopathologic examination and computed tomography, magnetic resonance imaging and PET / CT examinations, and a brief literature review. Conclusion: We report a case of Brunner’s gland hyperplasia mimicking neoplasia on computed tomography, magnetic resonance imaging and PET / CT, demonstrating a diagnostic challenge and the importanceof knowledge of differential diagnoses in the evaluation of duodenal masses.Keywords: Brunner glands, Hyperplasia, Hamartoma, Duodenal neoplasms, Gastrointestinal tract, Diagnostic imaging

Duodenum

The duodenum develops from endoderm of the caudal portion of the foregut and the cranial portion of the midgut. It is roughly 26 cm length, extending from the pylorus to the ligament of Treitz. Brunner glands secrete a bicarbonate-rich mucus that is protective to the duodenal mucosa and provides an alkaline environment for digestive enzymes to activate. Duodenal ulcers, often caused by Helicobacter pylori, can cause epigastric pain. UGI and EGD studies can show ulcers or masses in the duodenum. Severe bleeding, perforation, and obstruction caused by duodenal ulcers are managed surgically. Complications of duodenal surgery may include bleeding, anastomotic leak or stricture, bile duct injury, pancreatitis or leak, reflux esophagitis, or dumping syndrome.

Histological Aspects of Brunner’s Glands in Chinchillas (Chinchilla lanigera)

Since their discovery, Brunner’s glands have been an attractive subject of research. The study aimed to investigate the structure, the topography, and the degree of development of the Brunner’s glands in chinchillas through light microscopy. Transversal fragments from the duodenum of 5 chinchilla males were histologically processed by classical paraffin technique. Brunner glands are much more developed and proportionally, they occupy at least three times more space than the Lieberkuhn glands. In many places, Brunner glands are clustered, suggesting that more than one such gland spills its secretion product through a common Lieberkuhn gland in the space between villi. We can affirm that Brunner glands, after their disposition, appearance and absence of distinct muscularis mucosae, are disposed into the thickness of the mucosa and submucosa in chinchilla (together with the Lieberkuhn glands) and not strictly in the submucosa as in other mammals.

Perubahan Histologik Postmortem pada Kelenjar Brunner Hewan Coba

Studies of postmortem histological changes in digestive system showed a variety of changes related to postmortem time. This study was aimed to obtain the histological changes of Brunner gland within 24-hour interval using a domestic pig as model. This was a descriptive study. Samples of duodenum were taken at several time intervals, as follows: 0 hour, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 12 hours, 14 hours, 16 hours, 18 hours, 20 hours, 22 hours, and 24 hours. The results showed that the earliest histological changes occurred at 3 hours postmortem which showed congestion, widened gland lumen, as well as hydrophic degeneration of gland cells. At 7 hours to 22 hours postmortem the changes became more visible and were associated with lysis of the gland cells. At 24 hours postmortem the lysis had covered >50% of the gland cells, however, the Brunner glands could still be identified. Conclusion: The earliest changes occured at 3 hours postmortem in the forms of congestion, widened gland lumens, and hydrophic degeneration of gland cells which became more visible at 7-22 hour postmortem associated with gland cell lysis. The cell lysis covered most of the gland cells at 24 hours postmortem, however, the Brunner glands could still be identified.Keywords: duodenum, autolysis, postmortem. Abstrak: Berbagai penelitian mengenai perubahan histologik postmortem dari organ sistem pencernaan telah dilakukan pada hewan coba yang memperlihatkan variasi perubahan histologik sehubungan dengan waktu postmortem. Penelitian ini bertujuan untuk mendapatkan gambaran perubahan histologik postmortem pada kelenjar Brunner hewan coba dengan interval waktu 24 jam. Jenis penelitian ialah deskriptif yang menggunakan babi domestik sebagai hewan coba. Interval waktu pengambilan sampel dari bagian duodenum ialah: 0 jam, 1 jam, 2 jam, 3 jam, 4 jam, 5 jam, 6 jam, 7 jam, 8 jam, 9 jam, 10 jam, 12 jam, 14 jam, 16 jam, 18 jam, 20 jam, 22 jam, dan 24 jam postmortem. Hasil penelitian mendapatkan bahwa perubahan awal terjadi pada 3 jam postmortem yang menunjukkan kongesti dan lumen kelenjar melebar, serta degenerasi hidropik pada sel-sel kelenjar Brunner. Perubahan semakin tampak pada 7 jam sampai 22 jam postmortem, dan mulai terjadi lisis sel-sel kelenjar Brunner. Pada 24 jam postmortem lisis yang terjadi telah mencapai sekitar 50% sel kelenjar tetapi kelenjar Brunner masih dapat diidentifikasi. Simpulan: Perubahan awal terjadi pada 3 jam postmortem yang menunjukkan kongesti dan lumen kelenjar melebar serta degenerasi hidropik pada sel-sel kelenjar Brunner yang terus berlangsung disertai lisis sel-sel kelenjar yang pada 24 jam postmortem telah mencapai sebagian besar sel kelenjar tetapi kelenjar Brunner masih dapat diidentifikasi.Kata kunci: duodenum, autolisis, postmortem